FAQ Directory

Unfortunately, the AMA has not released a CPT II code for a systolic reading of between 140 and 150 mmHg, or under 150 mmHg. We updated the CBPH measure to align with new blood pressure guidelines; if there are patients whose systolic reading falls between 140 and 150 and it is captured in other kinds of supplemental data, they can be included in the numerator. Our data suggests that use of CPT II codes to retrieve this data is uncommon. This data is available in EHRs as well as via supplemental sources such as registries and laboratory data. There is a note to this effect in the specification for the CBPH measure on page 50 of the manual (http://www.iha.org/pdfs_documents/p4p_california/MY-2014-VBP4P-Manual- 20141201.pdf).

This is similar to the way the HbA1C <8.0% is calculated, as there is not a CPT II code specific to <8.0%. More information can be found in the manual on page 66 (http://www.iha.org/pdfs_documents/p4p_california/MY-2014-VBP4P-Manual- 20141201.pdf).

IHA 2014

Yes. The Agreement for Health Plan Accreditation Survey (the “Agreement”), specified in the “Organization’s obligations” section of the standards and guidelines, requires the organization to provide NCQA written notice within thirty (30) calendar days of the final determination by a state or federal agency with respect to request for corrective action, imposition of sanctions, changes in licensure or qualification status, if applicable, or violation of any federal or state law that affects the Scope of Review under the Standards and Guidelines. These are termed Reportable Events.

CM 2013

The organization must notify NCQA, in writing, within thirty (30) calendar days of the issuance of the notice of sanctions, issuance of a fine or issuance of a request for corrective action. 

The organization must also complete an annual attestation signed by an officer, or other authorized signatory of the organization, affirming that it has notified NCQA of all Reportable Events specified within the Agreement. NCQA-accredited health plans that reports HEDIS results include the attestation with its submission of the annual IDSS attestation submission for HEDIS® reporting.  Other health plans submit the completed attestation electronically to NCQA-Accreditation@ncqa.org. 

CM 2013

The organization must report the occurrence of any of the following actions by any federal or state regulatory authority:

• Issuance of Intermediate Sanctions and/or suspension of enrollment by CMS or any other federal or state regulatory authority.
• Issuance of any fine equal to or exceeding $50,000 related to Organization’s operations by CMS or any other federal or state regulatory authority.
• Issuance of any request for a corrective action by any federal or state regulatory authority where the substance of such corrective action relates to the Organization’s handling of utilization management decisions, network adequacy, benefit denials, complaints, grievances, appeals or other important patient safety matters. 

The above actions are referred to as the “final determination” within the Agreement.

CM 2010

Yes. The PCS system will be moved to a new Web site—http://my.ncqa.org—by the end of April. Customers who access the old PCS site will be automatically rerouted to the new site. The new site takes the same login and password; you will not need to change them.

HEDIS 2015

Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life should be reported using only the administrative methodology as specified in the 2015 QRS Technical Specifications (http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/2015-QRS-Measure-Technical-Specifications.pdf). Hybrid specifications are not available for this measure in the QRS.  The W34 measure is listed as a measure in the sample size table of the QRS Sampling Guidelines and was a misprint which will be corrected in the 2016 QRS Measure Technical Specification.
 
For organizations who have started medical record review for W34, please note, the IDSS will only accept the administrative elements of the measure for QRS.

Exchange 2015

Yes. Nurse practitioners acting as chief nursing officers may approve clean files in states where nurse practitioners can practice independently, or independently with a collaborative physician arrangement.

Yes. Because the organization uses the same practitioner network for all product/product lines, and all practitioners are subject to CR file review during an NCQA Accreditation Survey, the file is eligible to receive automatic credit. This is an exception to the Product Match policy posted on Policy Updates page.

No. Organizations with submissions before July 1, 2015, are reevaluated on the HEDIS measures in effect at their last survey. Organizations submitting after June 30, 2015, are reevaluated on the HEDIS measures in effect for that reporting year.

The intent is to use the most current information for the ESRD exclusion. If ICD-9-CM is used, then any code from the value set during the measurement year excludes the member from the denominator. If the MARx System output is used, then the most recent version applies. Although the time frames are not consistent between ICD-9-CM and RxHCC, it is the most current information to identify patients with ESRD. ICD-9-CM is preferred, but if it is not available, the most current MARx System output can be used.

IHA 2014

Yes, all fills during the treatment period should be considered. Calculate the average daily dose for each High-Risk Medication fill using the formula (quantity dispensed x dose)/(days supply). If the average daily dose for any two fills of the HRM exceed the threshold, then the member is numerator compliant.

IHA 2014

POs have the option of excluding pediatricians from the Controlling High Blood Pressure e-measure denominator.

IHA 2014